title: Toward High-Value Care: A Quality Improvement Initiative to Reduce Unnecessary Repeat Complete Blood Counts and Basic Metabolic Panels on a Pediatric Hospitalist Service.
abstract: OBJECTIVE
  Achieving high-value health care is a goal of health care providers who strive to increase quality and decrease cost. Decreasing laboratory tests is a potential method to increase value. We used quality improvement methodology to decrease the percentage of unnecessary complete blood counts (CBCs) and basic metabolic panels (BMPs) obtained on a pediatric hospital medicine service from 13.5% to <5%.
  
  
  METHODS
  A pre- and postintervention design was conducted including all patients admitted to 2 hospital medicine teams between May 2013 and December 2014. Multiple interventions linked to key drivers were tested through rapid plan-do-study-act cycles. Primary and secondary outcome measures, percent reduction of unnecessary CBCs and BMPs, and consecutive day tests were analyzed using statistical process control. Total billed charges, laboratory charges, 7-day readmission rates, and length of stay were compared pre- and postintervention.
  
  
  RESULTS
  Primary outcome of unnecessary CBCs and BMPs was reduced from a baseline of 13.5% to 4.5%. Secondary outcome measure of consecutive day testing was reduced from 20.9% to 8.5%. Median laboratory charges decreased significantly ($842 [$256-$1863] vs $800 [$222-$1616], P = .002), with no significant differences in total billed charges, 7-day readmission rates, or length of stay.
  
  
  CONCLUSIONS
  Rapid cycle plan-do-study-act methodology, initially focusing on the inclusion of a daily laboratory plan in progress notes, was an effective means to improve laboratory utilization and decrease laboratory charges without adversely affecting other quality measures. Spreading these efforts to different patient populations and laboratory tests could have a demonstrable effect on the value of health care.
authors.affiliation: Departments of Pediatrics, Division of Hospital Medicine, and david.p.johnson.1@vanderbilt.edu.
authors.forename: David P
authors.initials: DP
authors.lastname: Johnson
authors.affiliation: Departments of Pediatrics, Division of Hospital Medicine, and.
authors.forename: Carrie
authors.initials: C
authors.lastname: Lind
authors.affiliation: Departments of Pediatrics, Division of Hospital Medicine, and.
authors.forename: Sarah E S
authors.initials: SE
authors.lastname: Parker
authors.affiliation: Pediatric Residency Program, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee;
authors.forename: Christian
authors.initials: C
authors.lastname: Beuschel
authors.affiliation: Pediatric Residency Program, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee;
authors.forename: Stacey
authors.initials: S
authors.lastname: VanVliet
authors.affiliation: Department of Pathology, Microbiology, and Immunology, Vanderbilt University School of Medicine, Nashville, Tennessee; and.
authors.forename: James
authors.initials: J
authors.lastname: Nichols
authors.affiliation: Department of Pathology, Microbiology, and Immunology, Vanderbilt University School of Medicine, Nashville, Tennessee; and.
authors.forename: Carol A
authors.initials: CA
authors.lastname: Rauch
authors.affiliation: Cincinnati Children's Medical Center, Cincinnati, Ohio.
authors.forename: Brenda
authors.initials: B
authors.lastname: Lee
authors.affiliation: Cincinnati Children's Medical Center, Cincinnati, Ohio.
authors.forename: Stephen E
authors.initials: SE
authors.lastname: Muething
mesh_terms: D001772:Blood Cell Count / Q000191:economics*; D002648:Child; D019963:Clinical Chemistry Tests / Q000191:economics*; D064790:Clinical Laboratory Services / Q000191:economics / Q000706:statistics & numerical data; D017046:Cost Savings / Q000379:methods; D004469:Economics, Hospital; D006776:Hospitals, Pediatric / Q000592:standards; D006801:Humans; D007902:Length of Stay / Q000191:economics; D017063:Outcome Assessment, Health Care; D015397:Program Evaluation; D058996:Quality Improvement / Q000458:organization & administration*; D019564:Unnecessary Procedures / Q000191:economics / Q000706:statistics & numerical data